CONSULTANTS AND PRIVATE SPECIALISTS UK

PRIVATE SPECIALISTS

UK

0800 561 9000

| [email protected] | www.medicalprotection.org

Section A – Personal details

Will all your medical practice be carried out in United Kingdom? Yes No

(If no please give full details. If necessary please continue on a separate sheet)

What percentage of your clinical time is spent in England/Wales Northern Ireland Scotland

If you are registered to practise in any other countries please state which:

Address in UK for correspondence

Postcode Email address Daytime telephone Evening telephone Mobile telephone Title First name Surname

Previous name if any Date of birth (DD/MM/YYYY)

Gender Male Female

GMC registration number Degrees and diplomas

Medical school

Month and year of graduation (MM/YYYY)

Please complete in BLOCK CAPITALS, sign and return to: Membership Operations, Medical Protection Society, Victoria House, 2 Victoria Place, Leeds LS11 5AE, UK.

If your application for membership of MPS is approved, it will be dated from the day following receipt of

your application unless you specify a later start date in the area provided: D D M M Y Y Y Y

0126:02/15

Please read the relevant Information for applicants and

Membership guidance for your application for MPS membership. If you do not have these documents please let us know so that we can send them to you. Contact us by telephone on 0800 561 9000 or via email at [email protected]

Please read all of the important

additional information provided

Please read the relevant Membership guidance

you do not have these documents please let us know so that we can send them to you. Contact us by telephone on

via email at [email protected]

1. Have you had any professional indemnity/insurance before? Yes (Please go to Q2) No (Please go to Q4)

2. Please give the name of all other organisations and the dates during which you were a member or policyholder. If you were previously a member of MPS, please give your membership number and your name at the time (if it has changed)

Organisation From

(DD/MM/YYYY) (DD/MM/YYYY)To MPS number Name Other membership or policy number

3. Have there been any gaps in your professional indemnity (excluding NHS indemnity) during the last ten years? (If in doubt please indicate YES.) If you answer YES please confirm the dates and the reason for any gap below.

Yes No

4. Have there been any breaks in your clinical practice in the last 2 years? (If in doubt please indicate YES.) If you have answered YES please confirm the dates and the reason for any gap. Please also provide details of any continuous professional development or refresher training that has been undertaken.

Yes No

5. Have you ever been refused professional indemnity/insurance, including refusal to renew or been offered limited or conditional terms or a higher/enhanced subscription/premium? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words providing dates and reasons, including copies of any correspondence.

Yes No

6. In the last 10 years have you ever been the subject of any complaint(s) arising out of your professional practice which have not been resolved at local level. If you have answered YES please provide full details of the complaint(s). The details must include a summary in your own words of the events leading to the complaint(s), dates, the extent of your involvement and the final outcome.

Yes No

Section B – Previous History

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In this section you must include details of any matter in which you have been named or involved. Please include any pending, unresolved or closed issues, even those already reported to MPS. Failure to disclose full and accurate details about your previous history may delay your application. If necessary please continue your answers on pages 5 to 7.

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If you have answered YES to any question on pages 2 and 3 please provide details as requested. Use pages 9 to 11 if needed. Failure to disclose full and accurate details about your previous history may delay your application.

7. Have you ever been involved in any claim for compensation arising out of your professional practice or are you aware of any incident that might become a claim? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words of the events leading to the claim(s) declared, including dates, the extent of your involvement and also the final outcome.

Yes No

8. Have you ever been the subject of a disciplinary inquiry by your employer or had practice privileges refused/withdrawn/made conditional by a private health care provider? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words to include dates, the extent of your involvement and also the final outcome. Copies of any associated correspondence must be provided.

Yes No

9. Have you ever been subject to any referral, complaint, inquiry or investigation or hearing by the GMC or any other registration body or had conditions imposed on your practice or been suspended or erased from a medical register? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words of the events leading to the registration body inquiry/ investigation, including dates, the extent of your involvement and you must provide copies of any final determination letter(s).

Yes No

10. Have you ever been cautioned by the police in respect of, or convicted of, any criminal allegation (including road traffic offences)? If you have answered YES please provide a summary in your own words to include the nature of the offence, the final outcome or the current position and whether the offence was reported to any registration body.

Yes No

11. Are there any other issues of which MPS might reasonably need to be aware when considering your application for membership? (If in doubt please indicate YES.) If you have answered YES please provide all relevant information below.

Yes No

1. Please tick below to indicate your status:

Substantive NHS consultant

Locum NHS consultant Honorary NHS consultant

Private specialist ONLY (no NHS work) Pharmaceutical physician

Palliative medicine physician Ophthalmic medical practitioner Research clinician

Part-time Department of Work and Pensions (Benefi ts Agency) Public health physician

Other – including academic appointments (Please specify):

2. Please confi rm the specialty/ies in which you practice and if you are on the GMC Specialist Register for each specialty. (See information/12) Please note: List Obstetrics and Gynaecology as separate specialties.

Main specialty: Are you on the specialist register? Yes No

Other specialty 1: Are you on the specialist register? Yes No

Other specialty 2: Are you on the specialist register? Yes No

3. Are you in a salaried position that is NOT covered by any employer/NHS indemnity? 4. Do you do any private practice EXCLUDING medicolegal work category 2 work?

5. Please indicate expected income from unindemnifi ed private practice for which you require MPS indemnity. (See Information/12)

Please provide details of your expected income EXCLUDING any NHS salary or salary from an employer who provides you with indemnity.

Include any income paid into department funds or charity Exclude any medicolegal income

Exclude any category 2 work eg, insurance reports and cremation certifi cates Each specialty should be shown separately as in Q2. Do not combine income fi gures Include any salary that is not covered by any employer/NHS indemnity

Approx. gross income for main specialty £ approx. gross income:

Approx. gross income for other specialty 1 £ approx. gross income:

Approx. gross income for other specialty 2 £ approx. gross income:

Approx. expenses for all specialties combined (See Information/12) £ approx. expenses:

6. Do you do any medicolegal work? Please note: Medicolegal work is defi ned as “examinations and/or reports prepared in the context of prospective and/or actual proceedings in the civil and criminal courts and/or tribunal proceedings.”

Yes No

Section C – Professional status and scope of practice

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7. What is your approximate gross income and expenses from medicolegal work? £ approx. gross income + expenses:

8. Do you perform any private endoscopy within your specialty?

Yes No

9. Do you perform any private bariatric procedures within your specialty?

Yes No

10. For Radiologists only.

Do you perform any private interventional procedures for diagnosis or treatment?

(We define interventional radiology as the use of minimally invasive image guided procedures to diagnose and treat

disease. This includes the taking of biopsies and the use of intravascular catheters to introduce contrast media (peripheral IV injection via venflon type cannula is not classed as an interventional procedures.)

Yes No

11. If Yes, do any of these interventional procedures involve the cervical and/or cerebral vasculature or direct interventions to the spine, meninges and/or brain?

Yes No

12. Do you perform any private fetal anomaly scanning?

Yes No

13. For Ophthalmologists only. Do you do any private refractive laser surgery?

Yes No

14. For Ophthalmologists only. For which commercial organisations do you work? (Please tick all that apply)

Optimax Ultralase Maxivision

Other (please specify):

15. For General surgeons only. Do you do any private bariatric surgery?

Yes No

16. For Orthopaedic surgeons only. Do you perform any private spinal surgery, (surgical procedures performed on the spine and/or meninges)?

Yes No

17. For Paediatricians only. Do you undertake any private treatment of babies in the first 28 days of life? 18. For Obstetricians/Gynaecologists only.

How many private deliveries do you anticipate undertaking in the year ahead?

19. Please tick any cosmetic/aesthetic treatments/procedures you undertake. (See Information/9) Non-permanent and semi permanent fillers in the treatment of wrinkles and/or lip enhancement Botox

IPL

Microdermabrasion

Superficial chemical peels only (affecting the intra-epidermal layer) Sclerotherapy

Other. (Please specify below any other cosmetic/aesthetic procedures or treatments you undertake not listed above, eg laser treatments)

20. Please tick if more than 50% of your working time is spent in cosmetic/aesthetic medicine?

21. Please tick below if you undertake any cosmetic/aesthetic surgery in the specialties you identified in Q2

Main specialty Yes No

Other specialty 1 Yes No

Other specialty 2 Yes No

22. Are you involved in the treatment of elite/professional sportsmen or sportswomen? If you are unsure please contact the membership

helpline on 0800 561 9000. (See Information/10)

Yes (please provide details below) No

23. If you are a substantive NHS consultant, please tell us what kind of contract you have. (Please tick one box only)

OLD standard NHS contract

NEW standard NHS contract (from 2004)

Other contract type (Please specify):

24. If you have an old standard NHS contract, please specify which type of contract you hold. (Please tick one box only)

Whole time Maximum part-time Part-time

Honorary

25. NHS consultants with a NEW standard NHS contract only.

How many weekly programmed activities are you contracted to perform? Number of weekly programmed activities:

26. NHS consultants with a NEW standard NHS contract only. Is your contract a job share contract?

Yes No

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27. Where do you do your private practice? (Please tick all that apply)

Private consulting rooms/clinic Private hospital

NHS premises Home

Other (Please specify):

28. Do you have admitting privileges at a private hospital/clinic?

Yes No

29. Are you recognised as a specialist by one or more private healthcare providers eg, Spire, PPP etc.?

Yes No

30. Do you (wholly or partly) own/manage the healthcare premises from which your private practice is conducted?

Yes No

31. If you do any private practice, how is this practice run? (Please tick all that apply)

Sole trader (independent contractor)

Limited liability company in which you are a shareholder, but not a director Informal group arrangement (no contract)

Limited liability company in which you are a director, but not a shareholder Partnership

Limited liability company in which you are a director and a shareholder

Other (Please specify):

32. Do you employ staff in your private practice?

Secretary (Specify number employed):

Administrator/Manager (Specify number employed):

Nurse (Specify number employed):

Other (Specify role/number employed):

If you are submitting additional sheets or correspondence, please tick here.

In order to provide you with the best possible service we would like to inform you of other products and services off ered by us that we believe may be of interest to you. If you do not wish to receive such information, either via post or email, please tick here.

Signature Date D D M M Y Y Y Y

IMPORTANT! – Please read and sign below

Please tell us why you have chosen MPS – Your comments are important to us, please tick below

1. Personal recommendation

2. Competitive subscription rates

3. MPS membership co-ordinator, please provide their initials:

4. Group arrangement

5. Dissatisfaction with previous organisation

6. Other (please provide details in the space provided)

IMPORTANT! – Please read the following

Please note – You must sign and return this form with a current date. Any delay in returning this form may invalidate this application.

I wish to apply for membership of MPS subject to the Memorandum and Article of Association and upon payment of the appropriate subscription. I confi rm that I have read the important information on the guidance sheet. I understand that membership is not conferred automatically and is subject to approval.

I confi rm that the information I have provided is correct to the best of my knowledge and belief. I confi rm that I have completed and enclosed the payment instruction form. Payments made are subject to verifi cation and acceptance of a payment by MPS does not of itself confi rm membership and/or entitlement to request benefi ts.

Important – Your data

At times we will ask you to provide us with data and personal information including when you apply for membership, your subscription is renewed, your scope of practice changes and if you seek and we provide assistance to you. In applying for membership and by continuing as a member you agree that (i) we may hold and process your personal data including sensitive personal data (as defi ned in the United Kingdom’s Data Protection Act 1998 (the Act)) which you provide to us or which we fairly obtain from another source for the purposes of processing your membership renewal, the administration and provision of membership services, providing you with the benefi ts of membership (including, but not limited to, advice, assistance and indemnity), underwriting, risk assessment, marketing, education, research and audit during your membership and for a reasonable period aft er your membership terminates or an application for membership renewal is rejected by us or withdrawn by you and (ii) we may share such data with third parties who may also hold and process the data for the same purposes. Under the Act you have the right to ask us for a copy of any of your personal data which we hold, for which we make a nominal charge.

You also agree that (i) we may seek information relevant to any purpose for which you have agreed we may hold personal data regarding past and current matters from other professional defence organisations, insurance companies or employers with whom you have had professional indemnity arrangements or been employed and that they may release to us such information, (ii) if you are outside of the European Economic Area (EEA) your data may be transferred to, held and processed within the EEA and (iii) if you provide us with an email address or telephone number it may be used by us and third parties to contact you for any of the purposes for which you have agreed to allow us or them to hold or process your personal data.

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Please attach additional pages if necessary and clearly indicate the question number that you are providing details for. Failure to disclose full and accurate details about your previous history may delay your application.

Please clearly indicate the question number that you are providing details for below.

Additional space for answers to Section B – Previous history

Please clearly indicate the question number that you are providing details for below.

Additional space for answers to Section B – Previous history

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Please attach additional pages if necessary and clearly indicate the question number that you are providing details for. Failure to disclose full and accurate details about your previous history may delay your application.

Please clearly indicate the question number that you are providing details for below.

Additional space for answers to Section B – Previous history

0800 561 9000

| [email protected] | www.medicalprotection.org

Medical Protection Society Membership Operations, Victoria House, 2 Victoria Place, Leeds, LS11 5AE, United Kingdom.

Medical Protection Society

Date form sent Date received Approved by Date approved Processed Start date Joining reason Grade Status Specialty DP Access no. Membership no. Notes